Preoperative Fears Affect Postoperative Recovery

December 5, 2014

Patients who catastrophize—ruminate, worry, and exagerate their fears—often have worse outcomes than patient's who don't worry, especially after surgery. Researchers are now looking for ways to treat patients fears before surgery to prevent the development of chronic pain.

Clinicians are starting to become aware that a patient's mental health right before surgery effects postoperative recovery, especially when it comes to pain management. Catastrophizing is a psychological disorder that causes patients to ruminate, exaggerate, and feel helpless over their pain. When patients have an unhealthy perception of pain, their response to an operation can spiral out of control, intensifying the pain.

Indeed, researchers have found that catastrophizing is linked to adverse outcomes,1-2 especially after a surgery,3 where pain levels, length of hospital stays, usage of opioids, and time in rehabilitation may be affected. Catastrophizing, which relates to other cognitive distortions like depression and anxiety, can lead to chronic pain,4 particularly after a controlled injury.

Most recently, physicians studied how catastrophizing can impact recovery after standardized medical interventions, specifically total knee arthroplasty (TKA) procedures. >At this year's ANESTHIOLOGY 2014, the annual meeting of the American Society of Anesthesiologists, Asokumar Buvanendran, MD, an anesthesiology specialist and professor at the Rush University Medical Center in Chicago, Illinois, presented 2 extensive studies that looked into the causal ties between patients with catastrophic behavior and chronic pain incidence after TKA.5

Dr. Buvanendran and his team first conducted a robust meta-analysis of 7 studies, examining 661 total TKA patients. The data showed chronic pain occurred in 10% to 20% of the cases, and interestingly, those who had higher catastrophizing scores before surgery developed more chronic pain after their procedure.

These previous studies may have been limited by the fact that they looked at catastrophizing in isolation, though. Other psychological factors, like anxiety and depression, have been known to affect pain, and the studies left out other possible confounding factors, as well, like presurgical pain levels.

Mental Status and Pain

Researchers are becoming increasingly aware of how catastrophizing can mediate how patients not only experience their pain, but also how they respond to pain care, like opioids and rehabilitation.

"This is yet another study showing how important the psychological construct is in terms of influencing pain outcomes," said Beth Darnall, PhD, a clinical associate professor at Stanford University School of Medicine in Palo Alto, California. "What we need to do in this country is to prevent chronic pain from developing, so that we're not scrambling to figure out how to treat it on the backend," she said.

Pre-operative screening for catastrophizers isn't normally done outside of research settings. "While it's beginning to be introduced into routine practice, it is still not very common," Dr. Buvenandran said.

Dr. Darnall similarly recognized a vacancy of standardized catastrophizing pre-operation screenings. "It's not part of clinical care and the reason for that is we don’t have a system in place," Dr. Darnall said. "What has been missing and very much needed is a treatment."

Preoperative Therapy

Presently, Dr. Buvenandran is conducting further research into whether a pre-surgical intervention of cognitive behavioral therapy could possibly prevent chronic pain for occurring.

"If we can find (catastrophizing patients) and intervene—that's what we're trying to do with the randomized controlled trial—we'll see if intervention pre-operatively could make a difference post-operatively," Dr. Buvenandran said.

Dr. Darnall is also investigating effective ways to improve patient care for catastrophizing. In 2013, she created a specialized single-session treatment program, reporting positive results after a pilot study of over 70 participants.6

Dr. Darnall mentioned, however, that effective therapy programs can take multiple sessions, and other challenges, like the lack of free time and available local pain specialists, can make it hard for patients to get the help they need with their catastrophizing, especially before they undergo an operation.

Because of this, she is now developing and testing a fully online program, which will allow patients to conveniently receive treatment and education about catastrophic behavior through their computer.

The "million dollar question" remains as to what mechanisms enable catastrophizing to increase pain, Dr. Darnall said. Through these therapeutic interventions, as well as through neurological imaging,7 behavioral studies,8 and other forms of research, doctors continue to learn more about catastrophizing, bringing health care providers closer to affectively screening and treating patients afflicted with this condition.

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